Frequently Asked Questions: Health Care Reform and People Living With HIV

General Information

How Will Health Care Reform Help People With HIV?

Two key parts of the Patient Protection and Affordable Care Act, or ACA, will significantly benefit people with HIV. First, there are important improvements and protections to current health programs that serve people with HIV which include Medicaid, Medicare, group and individual insurance. Second, there are new health care options for people with HIV.

For example, Medicaid will serve everyone at or under 133% Federal Poverty Level or FPL (around $14,500 in 2011), regardless of their current health. People who do not qualify for Medicaid will be able to purchase affordable individual coverage as well as find federal help to pay for it. It's believed that as many as 70% of uninsured HIV-positive people who now get services through Ryan White and the AIDS Drug Assistance Program (ADAP) will qualify for Medicaid. Many of the remaining 30% will qualify for individual coverage with federal help.

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What Is Health Care Reform?

President Obama signed the ACA into law in March 2010. This law, commonly known as health care reform, dramatically expands health care coverage to uninsured and underinsured Americans. It also provides much needed protections and other positive changes to all the programs that make up the US health care system including Medicare, Medicaid, and individual and group insurance. It promises to significantly improve and stabilize health care coverage for people with HIV. Although the ACA is already law, many of its details are still being considered and put into place by federal and state agencies.

When Does the Law Take Effect?

The changes will be phased in over several years. Some are already in place, including allowing children to remain on their parents' insurance policy until age 26; providing new insurance options for people with pre-existing conditions; and ensuring insurance companies do not take away a person's coverage if they're sick. In 2014 people who are uninsured, underinsured and those struggling with health care costs will have protected access to new and affordable options.

What Is the Individual Insurance Mandate?

Beginning January 1, 2014, most people will be required to have health insurance. People who do not carry insurance will not face criminal charges but will be required to pay a fine. Parents will be responsible for their children's coverage and fines for children under 18 will be one-half of the adult's fine. Exceptions can be made for specific reasons, including:

Will Health Care Reform Differ by State?

For the first time, the federal government will establish a mandatory minimum benefits package. These benefits must be provided by various plans that a person can choose from in the Health Benefit Exchange and by Medicaid. (Here are the details of the Essential Benefits Package). Although the broad categories are in the law, the details will be decided by the Secretary of Health and Human Services.

However, differences will occur state by state. The new state Health Benefit Exchanges (see below) are expected to play a major role in health care reform when they're implemented in 2014. Since states have a lot of leeway in creating and running their own exchanges, people will likely see major differences in their insurance options and how to apply for them. However, Medicaid plans from state to state will probably have fewer differences although they may still vary somewhat in the types of benefits they offer

What Happens If My State Tries to Pull Out of Health Care Reform?

Medicaid expansion requires all states to have a Medicaid program. And although some states have recently threatened to pull out of Medicaid, they do not appear to be following up on those threats. It's difficult to see how they could run these critical programs without federal matching money.

As for state Health Benefit Exchanges, only Minnesota and Alaska did not apply for grants to begin developing an exchange. The ACA ensures that the federal government will step in and develop one if a specific state refuses. How this will happen has yet to be developed, but it will be included in the federal government's guidance on exchanges.

What Are Health Benefit Exchanges?

Starting in 2014, Health Benefit Exchanges will be set up as state or regional markets that sell various health insurance plans directly to individuals. The exchanges will primarily serve people with incomes above 133% FPL and small businesses with 100 employees or less. They are intended to be organized in a way that makes it easy to compare plans before choosing one.

How Will People Afford Insurance Under the Health Benefit Exchange?

In an effort to make insurance more affordable, the federal government will offer financial support (subsidies) and/or credits to help pay for premiums and other out-of-pocket costs. Subsidies will be available to persons with income between 134%-400% FPL. In addition, there will be a limit placed on the amount that individuals and families have to pay out of pocket for their health care.

Health Care Insurance Under Health Care Reform

How Will the Uninsured Get Insurance Under Health Care Reform?

Starting January 1, 2014, there will be two new insurance options. First, for uninsured people with incomes under 133% FPL, Medicaid will cover their health care costs. Second, for people with incomes above 133% FPL, they will be able to purchase insurance through their state Health Benefit Exchange. Subsidies and tax credits will be available to people with incomes between 133-400% FPL. Limits will be placed on the amount a person has to spend out of pocket for their health care.

Who Is Considered Uninsured?

Someone who is not eligible for, and is not enrolled in, a creditable public or private health insurance program is considered uninsured. Examples of creditable insurance include Medicaid, Medicare, health insurance from an employer, individual health insurance, and Veterans Administration coverage. Ryan White funded health services and/or drug coverage through the ADAP is not considered "creditable." Most people using only Ryan White services will have new insurance options available to them in 2014. Most will also be required to participate in that coverage as part of the individual insurance mandate (discussed above).

What Will Happen to People on Medicare?

People over the age of 65 and certain disabled people will continue to be eligible for Medicare. The ACA makes these following important improvements:

The law allows the amount that a person spends on their medicines through ADAP to count towards his or her True-out-of-Pocket (TrOOP) costs. (This change is to Medicare's prescription drug coverage, called "Part D.")

The law phases out the "doughnut hole" by 2020. (This is the gap in the Medicare drug benefit that forces people to pay full cost for their medicines or rely on ADAP for their prescription drugs.)

The law gives a 50% discount on brand name drugs while people are in the coverage gap.

The ACA also eliminates co-pays and deductibles for many preventive care services, and covers annual wellness visits. Many of the reforms improve the quality of care for people with Medicare. For example, hospitals will get incentives to improve patient care after discharge to prevent unnecessary re-admissions, and doctors will be encouraged to coordinate care that their patients receive from different specialists. A new agency will also be created to address the unique needs of individuals enrolled in both Medicare and Medicaid.

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